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J Am Dent Assoc, Vol 137, No 4, 468-473. © 2006 American Dental Association

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Expanding the scope of dental practice

	ABSTRACT

TOP ABSTRACT DENTISTRY'S ROLE IN DISASTER... THE ILLINOIS MEDICAL EMERGENCY... THE ILLINOIS DENTAL EMERGENCY... STANDARDIZED AND CERTIFIED... ILLINOIS DENTAL EMERGENCY... CONCLUSION REFERENCES

 
Background. Natural disasters, the potential for terrorism and weapons-of-mass-destruction events occurring within the continental United States necessitate that all licensed health care providers understand the National Incident Management System and be able to contribute to inoculation, mass casualty assistance and triage care of the populace.

Conclusions. Health care and political leaders constantly revise "all hazard" response plans, using the available health care assets that local, state and federal agencies bring to emergency events. Illinois Public Act 49-409 modifies the scope of dental practice within Illinois to allow for a dental emergency responder (DER).

Practice Implications. The DER is a dentist or dental hygienist "acting within the bounds of his or her license when providing care during a declared local, state or national emergency."

Key Words: Disaster medicine; National Incidence Management System; inoculation; drug dispensing; triage

Natural disasters such as hurricanes, tornadoes, earthquakes and floods, along with ongoing domestic and global terrorism and the potential for pandemic flu epidemics, demonstrate that complex disasters will require an increase in the numbers of available health care providers trained in emergency response. Recent disasters such as the ones experienced in the United States,^1–5 Indonesia⁶ and Turkey⁷ demonstrate that regardless of the advancement of science and technology, large-scale natural and manmade disasters continue to overwhelm local health services and emergency medical services (EMS) personnel and infrastructure. Damage and destruction to local infrastructure, clinics and hospitals can render these systems and the response personnel severely compromised for postevent triage and medical management.

Natural disasters are part of the fabric of life. The frequency, scope and magnitude of future disasters and mass-casualty events will increase as the global population continues to grow. Many countries strive to maintain emergency services^6,7 and mobile field hospitals that can be used for both defense and humanitarian purposes.⁸ In 2003, the World Health Organization and the Pan American Health Organization sponsored a workshop in El Salvador to discuss the pros and cons of using foreign field hospitals in the aftermath of natural disasters.⁸ One of the key recommendations to emerge from the workshop was to have friendly nations provide advanced trauma care and life support to a disaster site within 48 hours of the impact of an event. Urban areas face the most pressure to plan for and respond to large numbers of casualties and fatalities, whether driven by the "inevitable influenza pandemic" as described by Cinti,⁹ by failed human design, by terrorism, by earthquake or by hurricane.

In the United States, the 1993 and 2001 terrorist attacks on the World Trade Center and the 2001 attack on the Pentagon stimulated the federal and legislative branches of government to approve the largest U.S. government transformation since the formation of the Department of Defense. More than 22 different agencies, in whole or in part, underwent reorganization, in the establishment of the cabinet-level Department of Homeland Security.¹⁰ The mission of that agency is to protect the American homeland.¹⁰ The Federal Emergency Management Agency (FEMA) and several Department of Health and Human Services assets moved to the Department of Homeland Security, including the Office of Emergency Management, the National Disaster Medical System, the Strategic National Stockpile and the Metropolitan Medical Response System.

With the formation of the Department of Homeland Security, policy leaders recognized that an integrated, coordinated and comprehensive health care preparedness and response system was needed. Policy leaders recognized a lack of a consistent intrastate/interstate plan for coordination, communication and cooperation and a response structure that would work synergistically to bridge numerous public health and health care jurisdictions, civilian communities, response disciplines and first responders.

In an effort to address this issue, the Department of Homeland Security developed the National Incident Management System (NIMS). The president signed a directive requiring the establishment of a process that would lead to a unified and coordinated approach to health care preparedness and response during a disaster. The NIMS provides the policy directives for a national response plan¹⁰ and the framework for a national and statewide coordinated and hierarchical response structure within the United States.

	DENTISTRY’S ROLE IN DISASTER RESPONSE

TOP ABSTRACT DENTISTRY'S ROLE IN DISASTER... THE ILLINOIS MEDICAL EMERGENCY... THE ILLINOIS DENTAL EMERGENCY... STANDARDIZED AND CERTIFIED... ILLINOIS DENTAL EMERGENCY... CONCLUSION REFERENCES

 
Morlang,¹¹ in 1996, was the first to discuss the potential role of the oral health care provider in both military and civilian disaster response support. In 2002, Guay¹² discussed the potential role of the dentist in responding to bioterrorism. The U.S. military has a strong historical role in preparing military dentists to function as mass casualty and triage officers.^11,13 The armed forces train dental officers and dental staff members to provide triage care and anesthesia to casualties as a part of a medical response team. Along with these traditional medical duties, military dental officers take the lead in treating dental, oral and maxillofacial surgical needs in the battlefield environment.

Numerous leading medical^14–16 and dental^17–31 policy experts have discussed the dental disaster responder role since Sept. 11, 2001. All authors argue for fundamental changes to the modern dental curriculum, changes that require the training of oral health care providers to respond to mass disaster. Some authors^20,30 have suggested the need to amend state dental practice acts. Others have suggested the addition of an oral health care lexicon for the dental profession.^20,23,30

Illinois Public Act 49-409, which was signed into law on Aug. 2, 2005, and took effect Jan. 1, 2006, modified the scope of the practice of dentistry in Illinois. This act describes the dental emergency responder (DER) in the broader lexicon of the dental profession. The Illinois Dental Practice Act describes any dentist or dental hygienist as "acting within the bounds of his or her license when providing care during a declared local, state or national emergency." The Illinois statute describes the DER as a licensed dentist or dental hygienist "who is appropriately certified in emergency medical response, as defined by the Department of Public Health."

	THE ILLINOIS MEDICAL EMERGENCY RESPONSE TEAM

TOP ABSTRACT DENTISTRY'S ROLE IN DISASTER... THE ILLINOIS MEDICAL EMERGENCY... THE ILLINOIS DENTAL EMERGENCY... STANDARDIZED AND CERTIFIED... ILLINOIS DENTAL EMERGENCY... CONCLUSION REFERENCES

 
Early in 1999, responding to the increased national focus on terrorist threats and the growing national concern regarding the use of weapons of mass destruction (WMD), the Illinois Department of Public Health (IDPH), Office of Preparedness and Response, Division of Emergency Medical Systems and Highway Safety (EMSHS) perceived that Illinois was a full-spectrum–threat state. Full-spectrum threats include potential terrorist actions against agricultural, transportation, urban and waterway infrastructure from chemical, biological, radiological, nuclear and explosive events. The Division of EMSHS began meeting with a small group of similarly concerned emergency physicians and toxicologists to establish common reporting systems and standardized standing medical orders to address the full-spectrum–threat potential anywhere in Illinois.

The initial intent of the group and the Division of EMSHS was to assess the level of awareness and preparedness of the civilian emergency department personnel in Illinois to respond to a large-scale WMD incident that might overwhelm hospitals and surrounding communities. The IDPH encouraged coordination with this group and subsequently endorsed the formation of the Illinois Medical Emergency Response Team Executive Committee (IMERTEC, "www.imert.org"). The vision of IMERTEC, when activated by the director of the IDPH or his or her designee, is that it will respond to and assist the Illinois state emergency response teams with additional volunteer, emergency medical personnel and treatment oversight at mass casualty, disaster or WMD incidents within Illinois.

An Illinois emergency department physician (M.L.) was appointed as physician director for IMERTEC. IMERTEC is composed of a statewide group of health care leaders, fire commanders, Illinois National Guard leaders, civilian law enforcement personnel, Federal Bureau of Investigation leaders and other volunteers who volunteer their time and expertise to provide administrative oversight and recommendations to the Division of EMSHS. IMERTEC continues to evolve, as well as oversee, develop and amend, the statewide Illinois Medical Emergency Response Teams’ (IMERTs’) methods, systems and standing medical orders that would augment the efforts of local, county and state response teams during a disaster. IMERTEC also monitors the overall medical operations of IMERT, tracks emergent needs and plans for future flexibilities that might be needed to respond to ongoing and evolving threats.

Shortly after Sept. 11, 2001, IMERTEC was recognized formally by the Illinois Emergency Management Agency to be responsible for overseeing the development of the IMERT system and the various IMERTs. IDPH, IMERTEC and additional members from the disaster response, EMS and tactical EMS communities met to coordinate the formation of additional specialized IMERTs that would augment and integrate into all aspects of the state of Illinois and the Illinois National Guard response.

Three distinct types of disasters helped determine the IMERT structure, staffing and equipment needs. The largest IMERTs are the general disaster response teams. These teams are located throughout the state, drawing members from their own local communities and professional constituent societies. These general response teams are the primary responders teams that deploy, when local community resources are exceeded, during disasters or explosive terrorism events.

The other two IMERTs are the IMERT Urban Search and Rescue and the IMERT State Weapons of Mass Destruction teams. These teams are specialized teams whose membership is drawn from the general response teams. These teams undergo additional IMERT-sponsored training. All IMERTs are composed of licensed health care providers such as physicians, dentists, nurses, physician assistants, pharmacists, veterinarians, dental hygienists, EMS personnel and mental health specialists who have gone through IMERT-endorsed training. Additional personnel include communications and logistics specialists. A core objective of IMERT, since its inception, has been to provide domestic preparedness awareness education and training programs to all Illinois health care providers.

Within Illinois, the chief of the IDPH’s Division of Oral Health (L.N.L.) determined that the state’s oral health care providers could contribute to the disaster response effort within Illinois. He worked with the IDPH leadership, the Illinois State Dental Society (ISDS) leadership, the deans of Illinois’ colleges of dentistry and the constituent societies. This collaborative effort resulted in the realization that Illinois needed an academic training center that could provide standardized disaster response training for the state’s oral health care providers for "all hazard" disaster response.

The IDPH provided funding in the fall of 2003 to establish the Disaster Emergency Medicine Readiness Training (DEMRT, "www.demrt.org") Center within the Department of Oral Medicine and Diagnostic Sciences at the University of Illinois at Chicago (UIC) College of Dentistry. The DEMRT Center is a fully accredited American Medical Association (AMA) National Disaster Life Support (NDLS) Regional Training Center, serving Illinois and FEMA Region 5. The Center offers the complete AMA NDLS training curricula to all health care providers in Illinois and the region. The DEMRT Center also provides NIMS training, advanced cardiac life support, training, inoculation training and basic WMD identification training for oral health care providers.

	THE ILLINOIS DENTAL EMERGENCY RESPONDER

TOP ABSTRACT DENTISTRY'S ROLE IN DISASTER... THE ILLINOIS MEDICAL EMERGENCY... THE ILLINOIS DENTAL EMERGENCY... STANDARDIZED AND CERTIFIED... ILLINOIS DENTAL EMERGENCY... CONCLUSION REFERENCES

 
Through the mutual collaboration of the IDPH, IMERTEC and ISDS leadership and the UIC DEMRT Center, the DER concept was presented to the ISDS House of Delegates in the fall of 2004. The House of Delegates ratified it. Specific language subsequently was developed by the ISDS Governmental Affairs Office that would be introduced to the Illinois legislature for proposed incorporation into the Illinois Dental Practice Act.

Illinois Public Act 49-409 formally recognizes the DER in Illinois public law, the legal lexicon of Illinois and the Illinois Dental Practice Act. This act, which was passed by the Illinois General Assembly and signed into law by the governor of Illinois on Aug. 2, 2005, states that "a dentist or dental hygienist who is a DER is deemed to be acting within the bounds of his or her license when providing care during a declared local, state or national emergency."³²

The IDPH recognizes that during a disaster, the IMERT DER could be called on to provide basic triage care, airway care (including intubations), inoculation care, drug dispensing (during bioterrorism acts or pandemic disasters) and walking well care. This act indemnifies the properly credentialed Illinois oral health care provider who serves on a recognized IDPH IMERT during a declared disaster. Syndrome surveillance, inoculation and drug dispensing are key aspects of the role of the oral health care provider in Illinois and are consistent with recommendations from the American Dental Association and the recommendations of leading dental scientists.³³ The table delineates examples of additional responsibilities for the appropriately trained IDPH IMERT DER during the situation of a declared state or federal emergency.

	FOOTNOTES

Dr. Lampiris is the chief, Division of Oral Health, Illinois Department of Public Health, Springfield.

Dr. Cordell is the co-director, Disaster Emergency Medicine Readiness Training Center, Department of Oral Medicine and Diagnostic Sciences, College of Dentistry, University of Illinois at Chicago.

Dr. James is the director, Center for Public Health Preparedness and Disaster Response, American Medical Association, Chicago.

Dr. Guay is the chief policy advisor, American Dental Association, Chicago.

Dr. Lee is the medical director, Illinois Medical Emergency Response Team, John H. Stroger Jr. Hospital of Cook County, Chicago.

Ms. Stokes was the deputy director, Office of Preparedness and Response, Illinois Department of Public Health, Springfield, when this article was written. She now is retired.

Mr. Scott is the chief, Division of Emergency Medical Systems and Highway Safety, Illinois Department of Public Health, Springfield.

Interested readers may find more information on the Illinois Medical Emergency Response Team Executive Committee on its Web site at "www.imert.org" and on the Illinois Department of Public Health’s Disaster Emergency Medicine Readiness Training Center at "www.demrt.org".

The authors wish to express their deepest thanks to all the people who contributed to the establishment of the Illinois dental emergency responder (DER) concept. In particular, they assign special recognition to Illinois Department of Public Health and Illinois Medical Emergency Response Team leaders. Their tireless endorsement of the Illinois DER concept, and their behind-the-scenes efforts, were crucial to the successful passage of this effort in the Illinois General Assembly. They express their deepest gratitude for the support of Illinois State Dental Society (ISDS) Executive Director Robert Rechner and Governmental Affairs Officer Dave Marsh. Their adroit shepherding of the DER language through the ISDS House of Delegates, the Illinois Congressional subcommittees, various interest groups and passage by the Illinois General Assembly changed the Illinois Dental Practice Act. They wish to thank Jason Hansen, American Dental Association, Department of State Government Affairs, for his expert research of current state laws. They wish to recognize the expert insights of Jack Whitney, MD, Evanston Northwestern Healthcare system; Tim Conley, emergency medical technician-paramedic, Illinois Medical Emergency Response Team; and Jon Cox, Medical Reserve Corps Coordinator for the DuPage County, Ill., Medical Reserve Corps. They wish to recognize the support of Melissa Naiman, MS, emergency medical technician-basic. They wish to recognize and thank the efforts of Dean Bruce Graham, University of Illinois at Chicago, College of Dentistry, and Dean Michael Alfano, New York University School of Dentistry, for their tremendous leadership and support.

The preparation of this article was funded primarily by the Illinois Department of Public Health and partially by the National Institutes of Health, National Center for Complementary and Alternative Medicine (NIH/NCCAM grant K08-AT000987).

	REFERENCES

TOP ABSTRACT DENTISTRY'S ROLE IN DISASTER... THE ILLINOIS MEDICAL EMERGENCY... THE ILLINOIS DENTAL EMERGENCY... STANDARDIZED AND CERTIFIED... ILLINOIS DENTAL EMERGENCY... CONCLUSION REFERENCES

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Colvard, M. D. Articles by Scott, G. Search for Related Content PubMed PubMed Citation Articles by Colvard, M. D. Articles by Scott, G. Related Collections Practice Management